Pelvic Floor Disorders and Method of Childbirth

The October issue of The Green Journal includes a new article about pelvic floor disorders and method of childbirth. Many women say that fear of incontinence impacts their approach to childbirth, with some women choosing elective Cesareans specifically to prevent pelvic floor damage. The article, with Dr. Victoria L. Handa as lead author, discusses whether these concerns are accurate, and how they might impact method of childbirth.

The study looked at women 5-10 years after their first delivery, all of whom had delivered at Greater Baltimore Medical Center, classifying each woman by method of delivery:

cesarean without labor

cesarean during active labor

cesarean after complete cervical dilation

spontaneous vaginal delivery

operative vaginal delivery [including forceps and vacuum extraction]

If a woman had deliveries that fit into more than one category, she was classified according to the method of delivery that the authors felt had the highest likelihood of causing pelvic floor injury. The classification was determined by a review of obstetrical discharge records.

The authors then measures rates of four types of pelvic floor injury:

stress incontinence

overactive bladder

anal incontinence

prolapse (defined as at or beyond the hymen)

The injuries were first assessed through questionnaires given the women in the study, and then confirmed or re-assessed through physical examination. In addition, women who had undergone surgery or prior or current therapy for a specific pelvic floor disorder were considered as having it, even if they did not currently show symptoms.

The authors also looked at race (self-reported), maternal age at first delivery, obesity (measured by BMI at study enrollment), and cigarette smoking (“classified as ‘never’ or ‘ever’ based on whether a woman had smoked at least 100 cigarettes in her life”).

The authors concluded that a woman who had had at least one vaginal birth was “significantly more likely” to report stress incontinence or prolapse, but that “the most dramatic risk was associated with operative vaginal birth.” Symptoms of prolapse were uncommon across all groups but interestingly only 19% of women with prolapse reported “bothersome symptoms” from the prolapse; women who were obese upon examination or over age 35 at time of first delivery were more likely to report symptoms. The authors hope to continue to follow the women to determine whether those with reportable symptoms of prolapse were more or less likely to progress or regress.

Anal incontinence and overactive bladder were also both “significantly associated” with operative vaginal delivery but not spontaneous vaginal birth.

The authors found no difference in the rates of pelvic floor disorders in the cesarean groups, which is interesting considering that previous studies had indicated a link between active labor before a cesarean and pelvic floor injury. They did indicate, however, that the rate in each group was so small that an increase may not have been detectable under a doubling of the odds.

The study was limited by the small number of pelvic floor injuries in the group as a whole, and the low participation rate (50%) of all eligible women (based on medical records). “In addition, this is an observational study and we therefore cannot with certainty ascribe the incidence of pelvic floor disorders to obstetric events. We cannot exclude the possibility that unmeasured characteristics of the population or other exposures were relevant to the development of pelvic floor disorders.”

What do you think? What information did you have regarding possible pelvic floor disorders before giving birth? The authors state that they hope the study - which will continue looking at the cohort over time - “will be useful to women and their obstetric providers as they weigh childbirth options.” Does the information in this study impact how you view various methods of childbirth? What would make you change your mind, if anything, regarding pelvic floor disorders and childbirth? What other factors do you think might impact the rate?